Source · Investigations in the NHS

Independent investigation: Bianca ‘Kay’ Shepherd, Uxbridge (2015)

London Incident 10 Nov 2015 Subject Bianca ‘Kay’ Shepherd

Index summary

Paranoid schizophrenic fatally stabs housemate. Previous history of aggression and violence

Recommendations

4 total

1 Addressed to: Central North West London NHS Foundation Trust No Response Published

Link to recommendation 1

Recommendation · source text

The positions of individuals signing off key assurance documents should be stated.

2 Addressed to: Central North West London NHS Foundation Trust No Response Published

Link to recommendation 2

Recommendation · source text

The Trust should review the gaps in evidence we have identified with a view to providing NHSE with assurance within three months that it has comprehensively implemented its action plan.

3 Addressed to: NHS Harrow CCG No Response Published

Link to recommendation 3

Recommendation · source text

The CCG should assure itself within the next three months that it has robust systems and processes in place to monitor and test individual SI action plans. This should include finalising its SOP for the ‘internal management of Serious Incidents utilising “Datix”’

4 Addressed to: NHS Harrow CCG No Response Published

Link to recommendation 4

Recommendation · source text

The CCG should undertake an audit of Serious Incidents within the past 12 months with a view to confirming that action plans were monitored and tested.

Acceptance status

Per recommendation

No Response Published

Total recommendations

About this data

Acceptance status records the published response to each recommendation. Acceptance does not establish that an action has been completed.

Independent health investigation reports and reviews commissioned by government or NHS England.

About this investigation

Source & metadata

Independent investigation report. Recommendations and any published response are extracted below.